10.1.1 Non-steroidal anti-inflammatory drugs (NSAIDs)

Only prescribe an NSAID if the benefits of treatment clearly outweigh the risks and a need for an anti-inflammatory agent is identified.

Prescribing should be based on the safety profile of individual drugs and individual patient risk factors. Use the lowest effective dose for the shortest period of time to control symptoms.

Ibuprofen
  • Tablets 200mg, 400mg, 600mg (£2.87 = 400mg 3 times daily)
  • SuspensionSF 100mg/5ml (£1.13 = 100ml)
  • Gel containing 5% (£4.62 = 100g)

Indications

  • Pain and inflammation in rheumatic disease (including juvenile idiopathic arthritis) and other musculoskeletal disorders;
  • Mild to moderate pain including dysmenorrhoea (see notes below); postoperative analgesia; migraine; dental pain; fever with discomfort and pain in children; post-immunisation pyrexia

Dose

  • Adult and child over 12 years, initially 300–400mg 3–4 times daily; increased if necessary to maximum 2.4g daily; maintenance dose of 0.6–1.2g daily may be adequate
  • Pain and fever in children
    • 1–3 months, see BNFc
    • 3–6 months (body-weight over 5kg), 50mg 3 times daily (maximum 30mg/kg daily)
    • 6 months–1 year, 50mg 3–4 times daily (maximum 30mg/kg daily)
    • 1–4 years, 100mg 3 times daily (maximum 30mg/kg daily)
    • 4–7 years, 150mg 3 times daily (maximum 30mg/kg daily)
    • 7–10 years, 200mg 3 times daily (up to 30mg/kg daily, maximum 2.4g)
    • 10–12 years, 300mg 3 times daily (up to 30mg/kg daily, maximum 2.4g)
  • Rheumatic disease in children (including juvenile idiopathic arthritis)
    • 3 months–18 years (body-weight over 5kg), 30–40mg/kg, maximum 2.4g daily in 3–4 divided doses
    • in systemic juvenile idiopathic arthritis up to 60mg/kg, maximum 2.4g daily (unlicensed) in 4–6 divided doses

Notes

  1. Low dose ibuprofen remains the first line NSAID. If a patient says that they have tried ibuprofen check that the dose taken was 400mg 8 hourly, regularly.
  2. MHRA Drug Safety Alerts (June 2015): When prescribing or dispensing ibuprofen:
    1. avoid use of high-dose ibuprofen (2400mg or higher per day) in patients with established:
      1. ischaemic heart disease
      2. peripheral arterial disease
      3. cerebrovascular disease
      4. congestive heart failure (New York Heart Association [NYHA] classification II-III)
      5. uncontrolled hypertension
Indometacin
  • Capsules 25mg, 50mg (£3.39 = 50mg 8 hourly)
  • Suppositories 100mg (£17.61 = 10)
  • Injection 30mg in 1ml

Indications

  • Acute gout

Dose

  • 150-200mg daily in divided doses (combined oral and rectal treatment, maximum 150-200mg daily)
Ketoprofen
  • Gel containing 2.5% (£2.98 = 100g)

Indications

  • Relief of pain in musculoskeletal conditions

Dose

  • Apply 2-4 times a day for up to 7 days

Notes

  1. MHRA Drug Safety Update (Aug 2010) Patients should ensure that treated areas are protected from sunlight during the whole period of topical ketoprofen treatment and for 2 weeks after stopping; also carefully washing their hands after every application. Treatment should be stopped immediately if they develop any skin reaction after application, and seek their doctor's advice. Patients should be informed of the appropriate use of topical ketoprofen as outlined in the product information.
Naproxen
  • Tablets 250mg, 500mg (£2.30 = 500mg 12 hourly)

Indications

  • Pain and inflammation in rheumatic disease (including juvenile idiopathic arthritis) and other musculoskeletal disorders
  • Dysmenorrhoea
  • Acute gout

Dose

  • Rheumatic disease, 0.5–1g daily in 1–2 divided doses; child 2–18 years, juvenile idiopathic arthritis, see BNF for Children
  • Acute musculoskeletal disorders and dysmenorrhoea, 500mg initially, then 250mg every 6–8 hours as required; maximum dose after first day 1.25g daily; child under 18 years, see BNF for Children
  • Acute gout, 750mg initially, then 250mg every 8 hours until attack has passed; child under 16 years not recommended

Notes

  1. Naproxen may be a useful 2nd choice NSAID where a patient has cardiovascular risk factors (see notes above on cardiovascular risk)
  2. Naproxen is particularly useful where a sustained effect is required because it has a half-life of 14 hours, to be used in preference to diclofenac sustained release preparation
  3. Patients at high risk from developing gastrointestinal adverse effects should be prescribed omeprazole 20mg
  4. Naproxen e/c tablets offer no extra gastro-protection and are significantly higher in cost and are not included in the formulary
Diclofenac
  • Tablets 25mg, 50mg (£7.74 = 50mg 8 hourly)
  • Sustained release caps 75mg, 100mg (£9.69 = 75mg 12 hourly)
  • Dispersible tablets 50mg (£29.72 = 50mg 8 hourly)
  • Suppositories 12.5mg, 50mg, 100mg (£2.04 = 50mg x 10)
  • Injection 75mg in 3ml (£0.99 = 1 ampoule)

Indications

  • Pain and inflammation in rheumatic disease (including juvenile idiopathic arthritis) and other musculoskeletal disorders
  • Acute gout
  • Postoperative pain

Dose

  • Oral, 75–150mg daily in 2–3 divided doses
  • Sustained release, 75mg twice daily, 100mg daily
  • Suppositories, 75–150mg daily in divided doses
  • Juvenile idiopathic arthritis, child 6 months–18 years, by mouth, see BNFc
  • Postoperative pain, child 6 months–18 years, by rectum, see BNFc
  • Deep intramuscular injection into the gluteal muscle
    • acute exacerbations of pain and postoperative pain, 75mg once daily (twice daily in severe cases) for maximum 2 days; child 2–18 years, see BNFc
    • ureteric colic, 75mg then a further 75mg after 30 minutes if necessary
  • By intravenous infusion (in hospital setting)
    • acute postoperative pain, 75mg repeated if necessary after 4–6 hours; maximum 150mg in 24 hours for 2 days; child 2–18 years, see BNFc
    • Prevention of postoperative pain, initially after surgery 25–50mg over 15–60 minutes then 5mg/hour; maximum 150mg in 24 hours for 2 days

Notes

  1. Diclofenac sustained release preparations are considerably more expensive and should be reserved only for patients unable to comply with three times a day dosing for whom naproxen is not effective
  2. Diclofenac suppositories may be preferred to diclofenac injection (which may be painful when given IM) for the acute relief of pain e.g. biliary colic
  3. MHRA Drug Safety Update (June 2013) Diclofenac is now contraindicated in patients with established:
    1. ischaemic heart disease
    2. peripheral arterial disease
    3. cerebrovascular disease
    4. congestive heart failure (New York Heart Association [NYHA] classification II–IV)
  4. Patients with these conditions should be switched to an alternative treatment at their next routine appointment
  5. Diclofenac treatment should only be initiated after careful consideration for patients with significant risk factors for cardiovascular events (e.g. hypertension, hyperlipidaemia, diabetes mellitus, and smoking)
Celecoxib
  • Capsules 100mg, 200mg (£1.81 = 100mg 12 hourly)

Indications

  • Pain and inflammation in osteoarthritis, rheumatoid arthritis, and ankylosing spondylitis

Dose

  • Osteoarthritis, 200mg daily in 1–2 divided doses, increased if necessary to maximum 200mg twice daily
  • Rheumatoid arthritis, 100mg twice daily, increased if necessary to 200mg twice daily
  • Ankylosing spondylitis, 200mg daily in 1–2 divided doses, increased if necessary to maximum 400mg daily in 1–2 divided doses

Notes

  1. Discontinue if no improvement after 2 weeks on maximum dose
Etodolac
  • Tablets MR 600mg (£14.47 = 600mg daily)
  • Capsules 300mg (£7.60 = 600mg daily)

Indications

  • Pain and inflammation in rheumatoid arthritis and osteoarthritis

Dose

  • 300–600mg daily in 1–2 divided doses
Etoricoxib
  • Tablets 30mg, 60mg, 90mg, 120mg (£22.96 = 90mg daily)

Indications

  • Pain and inflammation in osteoarthritis, rheumatoid arthritis, and ankylosing spondylitis
  • Acute gout

Dose

  • Osteoarthritis, adult and child over 16 years, 30mg once daily, increased if necessary to 60mg once daily (maximum)
  • Rheumatoid arthritis and ankylosing spondylitis, adult and child over 16 years, 60mg once daily, increased if necessary to 90mg once daily (maximum). Once the patient is clinically stabilised, down-titration to 60mg once daily may be appropriate.
  • Acute gout, adult and child over 16 years, 120mg once daily (maximum) for maximum 8 days

Notes

  1. MHRA Drug Safety Update (July 2008): Patients whose blood pressure is persistently above 140/90 mmHg and inadequately controlled must not receive Etoricoxib. Furthermore, high blood pressure should be controlled before starting treatment, and should be monitored for 2 weeks after the start of treatment and regularly thereafter.
Meloxicam
  • Tablets 7.5mg, 15mg (£0.87 = 15mg daily)

Indications

  • Pain and inflammation in rheumatic disease
  • Exacerbation of osteoarthritis (short-term)
  • Ankylosing spondylitis

Dose

  • Osteoarthritis, adult and child over 16 years, 7.5mg once daily, increased if necessary to maximum 15mg once daily
  • Rheumatoid arthritis, ankylosing spondylitis, adult and child over 16 years, 15mg once daily, may be reduced to 7.5mg once daily; elderly 7.5mg daily

 

Home > Formulary > Chapters > 10. Musculoskeletal & joint diseases > 10.1 Drugs used in rheumatic diseases and gout > 10.1.1 Non-steroidal anti-inflammatory drugs (NSAIDs)

 

  • First line
  • Second line
  • Specialist
  • Hospital